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Last Days of Life (PDQ®)

Health Professional Version

Dying in the Hospital or Intensive Care Unit

No Further Escalation of Care

Patients with advanced cancer are often unprepared for a decline in health status near the EOL and, as a consequence, they are admitted to the hospital for more aggressive treatments. This complicates EOL decision making because the treatments may prolong life, or at least are perceived as accomplishing that goal. At that point, patients or families may express ambivalence or be reluctant to withdraw treatments rather than withhold them.

One strategy to explore is preventing further escalation of care. The goal of this strategy is to provide a bridge between full life-sustaining treatment (LST) and comfort care, in which the goal is a good death. One study [1] described the care of 310 patients who died in the intensive care unit (ICU) (not all of whom had cancer). For 95 patients (30%), there was a decision not to escalate care. The average time from ICU admission to deciding not to escalate care was 6 days (range, 0–37), and the average time to death was 0.8 days (range, 0–5). The interventions most likely to be withheld were dialysis, vasopressors, and blood transfusions. Fifty-five percent of the patients eventually had all life support withdrawn. The transition to comfort care did not occur before death for the other decedents for the following reasons: waiting for family to arrive, change of family opinion, or waiting for an ethics consultation.

Conversely, some situations may warrant exploring with the patient and/or family a time-limited trial of intensive medical treatments. It has been argued that clinicians may frame the decision to withdraw or not escalate care as missing the opportunity to die.[2] It can be argued, however, that refusing unwanted mechanical ventilation is equivalent to refusing oral hydration or nutrition. Thus, the patient may choose to forgo all LST at any time.

Withdrawal of Ventilatory Support

Two methods of withdrawal have been described: immediate extubation and terminal weaning.[3] Immediate extubation includes providing parenteral opioids for analgesia and sedating agents such as midazolam, suctioning to remove excess secretions, setting the ventilator to “no assist” and turning off all alarms, and deflating the cuff and removing the endotracheal tube. Gentle suctioning of the oral cavity may be necessary, but aggressive and deep suctioning should be avoided. In some cases, patients may appear to be in significant distress. Analgesics and sedatives may be provided, even if the patient is comatose. Family members and others who are present should be warned that some movements may occur after extubation, even in patients who have no brain activity. Such movements are probably caused by hypoxia and may include gasping, moving extremities, or sitting up in bed.[4] Immediate extubation is generally chosen when a patient has lost brain function, when a patient is comatose and unlikely to experience any suffering, or when a patient prefers a more rapid procedure.

Terminal weaning entails a more gradual process. Ventilator rate, oxygen levels, and positive end-expiratory pressure are decreased gradually over a period of 30 minutes to a few hours. A patient who survives may be placed on a T-piece; this may be left in place, or extubation may proceed. There is some evidence that the gradual process in a patient who may experience distress allows clinicians to assess pain and dyspnea and to modify the sedative and analgesic regimen accordingly.[5] In a study of 31 patients undergoing terminal weaning, most patients remained comfortable, as assessed by a variety of physiologic measures, when low doses of opioids and benzodiazepines were administered. The average time to death in this study was 24 hours, although two patients survived to be discharged to hospice.[6]

Paralytic agents have no analgesic or sedative effects, and they can mask patient discomfort. These neuromuscular blockers need to be discontinued before extubation. Guidelines suggest that these agents should never be introduced when the ventilator is being withdrawn; in general, when patients have been receiving paralytic agents, these agents need to be withdrawn before extubation. The advantage of withdrawal of the neuromuscular blocker is the resultant ability of the health care provider to better assess the patient’s comfort level and to allow possible interaction between the patient and loved ones. One notable exception to withdrawal of the paralytic agent is when death is expected to be rapid after the removal of the ventilator and when waiting for the drug to reverse might place an unreasonable burden on the patient and family.[7]

Regardless of the technique employed, the patient and setting must be prepared. Monitors and alarms are turned off, and life-prolonging interventions such as antibiotics and transfusions need to be discontinued. Family members should be given sufficient time to make preparations, including making arrangements for the presence of all loved ones who wish to be in attendance. They need to be given information about what to expect during the process; some may elect to remain out of the room during extubation. Chaplains or social workers may be called to provide support to the family.

References

  1. Morgan CK, Varas GM, Pedroza C, et al.: Defining the practice of "no escalation of care" in the ICU. Crit Care Med 42 (2): 357-61, 2014. [PUBMED Abstract]
  2. Cochrane TI: Unnecessary time pressure in refusal of life-sustaining therapies: fear of missing the opportunity to die. Am J Bioeth 9 (4): 47-54, 2009. [PUBMED Abstract]
  3. Marr L, Weissman DE: Withdrawal of ventilatory support from the dying adult patient. J Support Oncol 2 (3): 283-8, 2004 May-Jun. [PUBMED Abstract]
  4. Heytens L, Verlooy J, Gheuens J, et al.: Lazarus sign and extensor posturing in a brain-dead patient. Case report. J Neurosurg 71 (3): 449-51, 1989. [PUBMED Abstract]
  5. Truog RD, Cist AF, Brackett SE, et al.: Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 29 (12): 2332-48, 2001. [PUBMED Abstract]
  6. Campbell ML, Bizek KS, Thill M: Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. Crit Care Med 27 (1): 73-7, 1999. [PUBMED Abstract]
  7. Truog RD, Burns JP, Mitchell C, et al.: Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med 342 (7): 508-11, 2000. [PUBMED Abstract]
  • Updated: April 16, 2015